Secretary of State of Washington
Washington Talking Book & Braille Library
2021 9th Avenue • Seattle, WA 98121-2783 • (800) 542-0866 • (206) 615-0400
(206) 615-0418 TTY • (206) 615-0437 FAX • wtbbl@sos. •
Application for Free Institutional Library Service
Name of Facility___________________________________________________
Staff Contact______________________________________________________
Address__________________________________________________________
Street (or P.O. Box) Suite
_________________________________, Washington ___________________
City ZIP Code
Telephone (_______) _______________________ Extension _______________
Email Address _____________________________________________________
( Email me a username/password for the online catalog.
Number of persons unable to use regular printed material who will be served:
Talking Books __________ Braille __________ Large Print __________
Institutions, such as hospitals, nursing homes, and rehabilitation centers, which regularly serve clients meeting the eligibility requirements on Page 2, can apply for free library service. Registered institutions may borrow books and equipment in order to:
1. Demonstrate the service to new library users.
2. Provide library service to eligible short-term residents. (Long-term residents should be registered for individual library accounts.)
3. Use in group activities with residents who cannot use standard print.
Public libraries may also borrow talking book equipment for demonstration purposes and can establish a deposit collection of large-print books.
In compliance with RCW 42.56.310, application information is confidential and will be used only in relation to your library service.
Alternate Contact Information
Please give the name of a contact to use if the primary person cannot be reached:
Name_____________________________ Telephone (_____)________________
Certification of Eligibility
An administrator must sign below, certifying that the named institution serves persons who are unable to read or use standard printed material because of one or more of the reasons below and that the reading materials and equipment will be used by such persons only.
( Blindness. Visual acuity of 20/200 or less in the better eye with correcting lenses, or whose widest diameter of visual field subtends an angular distance no greater than 20 degrees.
( Visual Impairment. Inability to read standard printed materials without special aids or devices other than regular glasses.
( Physical Disability. Inability to turn pages or comfortably hold a book for extended periods of time as a result of physical limitations.
( Deafness and Blindness.
( Reading Disability. Reading disability, resulting from organic dysfunction, of sufficient severity to prevent reading of printed material in a normal manner.
Please note: Federal law (36 CFR 701.10) mandates that only doctors of medicine or osteopathy are allowed to certify cases of reading disability.
__________________________________________________________________
Certifier Signature Printed Name
__________________________________________________________________
Title and Occupation
__________________________________________________________________
Address City State ZIP Code
(______) __________________________________________________________
Telephone Date
Books and Equipment
All books and equipment are sent and returned through the mail free of charge. Please select below the services you would like to receive. If you have multiple residents that desire their own talking book players, they should be registered for individual accounts.
Talking books:
( Send me books on digital cartridge and a digital player needed to use them.
_____ Number of digital players needed (No more than 1 for every 4 users)
( Contact me with information on downloading digital recorded books.
( Send me cassette books and a special cassette player needed to use them.
_____ Number of cassette players needed (No more than 1 for every 4 users)
Send me these optional attachments:
( Headphones for private listening. Number needed ______
( A pillow speaker for listening in bed. Number needed ______
For the cassette player only:
( An application for a remote-control unit for individuals confined to bed, or who have low mobility or greatly restricted use of hands or arms.
( Key extension levers for individuals with limited use of hands or arms.
( An application for an amplifier with headphones for the hearing impaired.
( An application for a breath-activated switch.
Braille books:
( Send me braille books. Number needed ______
( Contact me with information on downloading Web-Braille books.
Large-print books:
( Send me large-print books. Number needed ______
Evergreen Radio Reading Service:
( Listen online at (high-speed Internet connection required).
□ Send me information on where I may purchase a special radio to get the over-the-air signal in the Seattle, Spokane and Tri-Cities radio listening areas. (The library does not have radios available for loan.)
Equipment policy: Playback equipment and special attachments are supplied to eligible persons on extended loan. If this equipment is not being used in conjunction with reading material provided by the Library of Congress and its cooperating libraries, it must be returned to the issuing agency. Your cooperation with returning these items in a timely manner is appreciated.
Reading Preferences
Please check preferred listening/reading levels:
( Adult
( Young Adult/High School
( Junior High
( 4th-6th Grade
( Kindergarten-3rd Grade
( Preschool
Indicate the types of books to be sent:
Favorite subjects and genres: __________________________________________
__________________________________________________________________
__________________________________________________________________
Favorite authors: ____________________________________________________
__________________________________________________________________
__________________________________________________________________
Special interests: ____________________________________________________
__________________________________________________________________
__________________________________________________________________
List any languages, other than English, in which you would like to receive books:
__________________________________________________________________
Please call or email the library at any time with special author, title, or subject requests, or if you have questions about your service. We look forward to serving you.
Choose one option for receiving books:
( I wish to have the library select books for me. The library will send books from the categories you indicated above, or from requests you send us. Each book you send back will automatically be replaced. You may receive a call from the library to talk about the kinds of books you would like to receive.
( I wish to receive only books I request. You will need to call us with lists of requests from our bimonthly catalog of new books or make requests through the online catalog in order for us to replace the books you return. No books will be sent if there are no requests in your file.
(rev. 1/2012)
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